The healthcare industry is a complicated, highly regulated industry that provides a product for serving every type of human condition in every combination possible. As such, detailed documentation of patient diagnosis, conditions, treatments, procedures and the frequency and time of each is mandatory.
Contrary to general belief, a hospital is not paid based on what the detailed bill indicates. Hospitals are generally paid on a Diagnostic Related Group (DRG) which is based on the patient's diagnosis that was the primary reason for admission to a hospital, complications involved with the patient's condition and/or during the patient's hospitalization and procedures performed during the hospitalization. Each different DRG (there are over 500) provides for different reimbursement. Furthermore, within a “grouping”, there are different sub-categories of reimbursement that are driven by the complications and treatment of those complications.
As an example, assume a patient is admitted to a hospital for congestive heart failure (CHF) and arrived from a nursing home with decubitus ulcers (bed sores). The patient's diagnosis would be CHF with complications, decubitus ulcers. Reimbursement for CHF with no complications would be one amount, for instance $4,000.00; reimbursement for CHF with complications would be an additional amount, for instance $2,000.00 or a total of approximately $6,000.00. However, documentation must be provided to support coding that this type of ulcer did exist and was treated. Treatment for bed sores is a combination of continually moving the patient to avoid the sores getting infected and may result in a bedside debridement (removal of the ulcer at the bedside). Documentation is generally provided in the form of the nurse remembering what was done at the bedside and then memorializing the medical procedure that was performed at the bedside in the patient's medical record (paper or electronic) upon returning to the nursing station.
From the time a nurse leaves the nursing station, enters a patient's room, performs treatment, returns to the nursing station and documents the events that took place in each patients room, many opportunities for disruption and interruption can transpire. Some studies suggest that up to thirty-eight percent (38%) of healthcare provider billings do not have complete coding and supportive documentation, thereby reducing reimbursement for that particular patient's admission and causing the entire system to subsidize these shortfalls in reimbursement.
Starting in October 2008, the Center for Medicare and Medicaid Services (CMS) (the Medicare program) will no longer reimburse hospitals for errors or non-events that took place during the patients stay. Using the same example of the patient with CHF and bed sores discussed above, it will now be necessary to document that fact that the patient had this condition “before” arriving at the hospital and was not caused by the hospital. CHF is easily proven to the satisfaction of CMS (fluid in the lungs, EKG tests, enzyme testing), but it is not unusual for elderly patients to develop bed sores if they have been lying in a bed for an extended period of time in the same position. However, it is much more difficult to document conditions such as bed sores that might develop in either facility. Care must be taken to meticulously document every existing condition that might require treatment during the stay at the facility, whether or not that condition is the primary reason for the patient being admitted to the facility.
Finally, it has been reported that insurers and CMS routinely require additional support for medical procedures and charges documented on the patient's bill. Some of those procedures may even require supplemental supporting documentation to corroborate the medical procedures and charges. In addition, up to 20% of all charged items are routinely disallowed by insurers and CMS, essentially without comment or any explanation. It is then up to the healthcare facility to provide persuasive documentation in support of the medical procedures and charges. In most cases, the only support can be found in the medical records, which may have already been submitted. In the vast majority of cases, the only type of supplemental supporting documentation that can be proffered is a written description of the medical procedures by a physician or charge nurse. Documentation that is not temporal with a medical procedure is by far the least persuasive type of support that can be provided.
Aside from patient billing matters, the quality of patient care is always best when all the facts are known and documented. Physicians rely on this documentation to become knowledgeable of the patients condition, improvement or deterioration, and the frequency of events and treatments. They need 100% of the information . . . not 62% of the information. If the written patient record is incomplete or unavailable, the quality of patient care may suffer.